1. Brain diseases: Substance abuse and co-occurring disorders Mark Publicker, MD FASAM

2. Addiction A chronic but treatable brain disease characterized by Loss of control Compulsive use Use despite known harm Relapse The emergence of a negative affect state

3. Questions Does mental illness cause substance abuse? Does substance abuse cause mental illness?

4. Questions Are there differences in populations  Primarily psychiatric  Primarily substance dependent

5. Comorbid substance abuse Common problem in psychiatric patients Contributes to treatment failure and non-compliance Increased health care costs

6. Neurobiology Same neurotransmitter systems  Dopamine  Serotonin  GABA  Glutamate  Endogenous opioids

7. Neurobiology Drugs of abuse interact and alter neural substrates of psychiatric disorders More neuro-psychological impairment

8. Rand Survey 2001 3% US population has co-occuring disorders Of these:  72% received no treatment in previous 12 months  Only 8% received both mental and substance abuse treatment  Only 23% of those in treatment received “appropriate treatment”

9. Current situation in US treatment systems Comorbid rates are high Different services are provided according to entry portal

10. Co-morbid psychiatric disorders Depression Anxiety disorders Bipolar disorder Schizophrenia

11. Co-morbid psychiatric disorders Attention deficit hyperactivity disorder Post traumatic stress disorder Antisocial personality disorder

12. Epidemiology substance abuse disorders 50% lifetime prevalence for psychiatric patients Among individuals with alcohol use disorders, about 22% will also have a drug use disorder Among individuals with a drug use disorder, almost half (47%) will have an alcohol use disorder Schizophrenia: 70%prevalence rates  Earlier onset of symptoms

13. Epidemiology Affective disorders are very common. Up to 67% of alcohol-dependent patients, 53% of cocaine-dependent patients, and 75% of opiate-dependent patients have comorbid affective disorders Approximately 25-50% of alcohol dependent individuals meet criteria for an anxiety disorder Approximately 30-60% of patients with an SUD have comorbid Antisocial Personality Disorder

14. 14

15. 15 Order of Onset Mental disorders typically emerge before comorbid substance use disorders This pattern is somewhat stronger for women than men Data from a large epidemiologic study found that the median age of onset of mental disorders was 11 yrs old as compared to 21 yrs old for substance disorder

16. 16 Diagnostic Difficulties Substance intoxication and withdrawal can mimic nearly any psychiatric disorder Stimulants/hallucinogens/cannabinoids = mania and schizophrenia Alcohol/opiate/sedative-hypnotic withdrawal = depressive and anxiety disorder

17. Diagnostic Difficulties Assess which disorder developed first Ask about symptoms during periods of abstinence. Minimum acceptable period of abstinence necessary for diagnostic clarity will differ by diagnosis:  Anxiety/depression: most symptom overlap, 2-4 weeks important.  Psychosis/mania 2-4 days sufficient in most cases.  Ask about family history Consult multiple sources of information

18. Substance Use and Suicide Substance induced depression Substance induced depression  May resolve quickly with treatment but is still very dangerous  Increased suicidal thoughts, ideation High risk group: Diagnosis of major depression + alcohol or drug abuse/dependence High risk group: Diagnosis of major depression + alcohol or drug abuse/dependence Rates are 20-120X the general population Rates are 20-120X the general population

19. Epidemiology Schizophrenia: substance abuse associated with higher rates of homelessness, non-compliance, medical illness and violence Bipolar disorder: rates estimated to be 50-70%  Associated with worse prognosis

20. Epidemiology Unipolar depression: 30-50%  Associated with treatment resistance and greater severity  Worsens alcohol dependence treatment outcomes

21. Epidemiology ADHD: 50% of substance abuse patients  Increases risk of substance abuse  Effective childhood treatment reduces risk

22. Epidemiology PTSD: increased risk of substance abuse  Hypothalamic and noradrenergic mechanisms  Substance abuse increases PTSD symptoms which in turn intensify substance abuse

23. Post traumatic stress disorder Withdrawal symptoms overlap with arousal symptoms Increased stress sensitizes the Locus Ceruleus

24. Post traumatic stress disorder Increased noradrenaline increases stress Increased fear responses in amygdala

25. Epidemiology - Nicotine Nicotine-dependent patients with comorbid disorders: 7.1% US population consume 34.2% of all cigarettes smoked

26. Self-medication hypothesis Nicotine decreases stress reactivity Schizophrenia: nicotine used to deal with negative symptoms:  Sleepiness  Dysphoria  Antipsychotic adverse effects  Improve cognitive function

27. Cannabis Heavy adolescent use increases psychiatric risk  Depression  Anxiety disorders  Schizophrenia

28. Summary High rates of comorbidity Each increases the risk of the other and complicates their management Concurrent treatment yields best results